Syphilis as a marker of ethnoracial inequalities in Brazil
Authors: Angelica E Miranda, Rita Cassia D Lima
Journal: The Lancet Global Health (2023)

The link between ethnoracial inequality and infectious diseases is influenced by historical, socioeconomic, and structural factors.1Ayorinde A Ghosh I Ali I et al.Health inequalities in infectious diseases: a systematic overview of reviews.BMJ Open. 2023; 13e067429Crossref PubMed Scopus (2) Google Scholar Brazil has a long history of inequalities, including those related to ethnoracial issues, rooted by the historical process of colonisation and enslavement. This process led to lasting disparities in areas like economics, culture, education, and health.2Lima M Prates I Racial inequalities in Brazil: a persistent challenge.in: Arretche M Paths of inequality in Brazil. Springer, Cham2019: 113-134Crossref Scopus (6) Google Scholar These disparities translate into reduced access and effectiveness of health care and lead to worst health outcomes for some groups.3Devakumar D Selvarajah S Abubakar I et al.Racism, xenophobia, discrimination, and the determination of health.Lancet. 2022; 400: 2097-2108Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar The Black population in Brazil faces issues with public social policies access, including to the public health system (Sistema Único de Saúde [SUS]),4Werneck J Racismo institucional e saúde da população negra Institutional.Saúde Soc. 2016; 25: 535-549Crossref Google Scholar highlighting racial inequalities in cases like maternal and congenital syphilis. Enny S Paixão and colleagues5Paixão ES Ferreira AJF Pescarini JM et al.Maternal and congenital syphilis attributable to ethnoracial inequalities: a national record-linkage longitudinal study of 15 million births in Brazil.Lancet Glob Health. 2023; 11: e1734-e1742Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar present the correlation between maternal and congenital syphilis and race in Brazil as being entwined with social, economic, and structural factors, rather than due to biological factors. Addressing this inequal access involves comprehensive public health strategies, including sexual education, prevention, early diagnosis, and adequate treatment for all, regardless of racial or ethnic background. Considering intersectionality, discrimination, and markers of social inequalities is crucial for confronting the discrimination that strengthens structural and institutional racism.4Werneck J Racismo institucional e saúde da população negra Institutional.Saúde Soc. 2016; 25: 535-549Crossref Google Scholar, 6Serrant L Silenced knowing: an intersectional framework for exploring Black women's health and diasporic identities.Front Sociol. 2020; 5: 1Crossref PubMed Scopus (9) Google Scholar Racial inequalities can substantially shape the health-care system's response to syphilis in Brazil and can influence the willingness of vulnerable communities to adhere to public health strategies. Racial inequality in Brazil is intricately linked to the prevalence and effects of syphilis in pregnant women, and consequently, to cases of congenital syphilis. This social issue demands intricate approaches, including aspects of dignified living conditions and social rights that incorporate the specific needs of vulnerable populations, as highlighted in the National Policy for Comprehensive Health Care for the Black Population since 2009.7Brasil Ministério da SaúdePolítica Nacional de Saúde Integral da População Negra: uma política para o SUS.https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_populacao_negra_3d.pdfDate: 2017Date accessed: August 26, 2023Google Scholar However, as of 2023, this policy has not been fully implemented within Brazilian health-care institutions, resulting in imposed inequalities on population groups that are severely affected by precarious living conditions, low educational levels, and violence that contribute to the production of inequities. The absence of an equity and comprehensive policy to address inequities goes against the constitutional mandates outlined in the guidelines of SUS; thus, reaffirming the distinct forms of discrimination and racism that have permeated the structure of our society since its inception. In 2022, national data on syphilis notification in pregnant women showed, in relation to the race criterion, that 53·3% of pregnant women diagnosed with syphilis were Parda/Brown, 27·0% were White, and 11·9% were Black. Most mothers of children with congenital syphilis declared themselves Parda/Brown (59·6%), followed by White (22·5%), and Black (8·7%). Black and Parda/Brown communities comprised most syphilis' cases (low education also was a frequent indicator). In Brazilian society, Parda/Brown and Black women represent approximately 56% of the population, and White women approximately 43% of the population.8Brasil Ministério da SaúdeBoletim Epidemiológico de Sífilis; número especial: Out.https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/especiais/2022/boletim-epidemiologico-de-sifilis-numero-especial-out-2022/viewDate: 2022Date accessed: August 23, 2023Google Scholar Other published data corroborate that syphilis infection rates are higher in areas with a higher concentration of Black and Parda/Brown populations, often associated with unfavourable socioeconomic conditions, lack of access to health information, and difficulties in accessing adequate health-care services.9Pinto R Valentim R Fernandes da Silva L et al.Use of interrupted time series analysis in understanding the course of the congenital syphilis epidemic in Brazil.Lancet Reg Health Am. 2021; 7100163PubMed Google Scholar It is important to point out that Brazil supports and adopts WHO policies for the elimination of mother-to-child transmission (MTCT) of HIV, syphilis, and hepatitis B infection. In 2021, the guide for certification of elimination of MTCT of HIV and/or syphilis was updated with the inclusion of syphilis in the subnational certification strategy towards the elimination of MTCT.10Brasil Ministério da SaúdeGuia para Certificação da Eliminação da Transmissão Vertical de HIV e/ou Sífilis.https://bvsms.saude.gov.br/bvs/publicacoes/guia_certificacao_eliminacao_trasmissao_vertical_hiv_sifilis.pdfDate: 2021Date accessed: August 26, 2023Google Scholar Several measures have been taken in this direction, but many challenges remain, mainly related to controlling congenital syphilis in Brazil. Syphilis has become one of the diseases that mirrors the many historical contradictions shaping persistent inequalities that predominantly affect the most vulnerable population. As argued by Paixão and colleagues,5Paixão ES Ferreira AJF Pescarini JM et al.Maternal and congenital syphilis attributable to ethnoracial inequalities: a national record-linkage longitudinal study of 15 million births in Brazil.Lancet Glob Health. 2023; 11: e1734-e1742Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar these disparities are intertwined with factors such as race, gender, education, and social class, as well as moral and religious stereotypes. The women (most of whom are Black or Parda/Brown, have low educational levels, are heads of households, and are unemployed or underemployed) are subject to various forms of neglect and abandonment, both by the state and their male partners. The lack of comprehensive sex education, inadequate access to health care, social stigmas, and cultural barriers contribute to a higher incidence of the infection among Black and Parda/Brown women and their babies. Health-care providers must establish a respectful and trusting relationship with these women to understand their needs and tie the gap in reaching equity in sexual health. Syphilis in pregnancy and congenital syphilis persist as one of the diseases reflecting the intricate intersections interwoven in the perpetuation of factors underpinning racism and other forms of violence present in Brazilian society, and a national mobilisation is needed to address these challenges to succeed in the process of eliminating congenital syphilis in the country. We declare no competing interests. Maternal and congenital syphilis attributable to ethnoracial inequalities: a national record-linkage longitudinal study of 15 million births in BrazilOnly through effective control of maternal syphilis among populations at higher risk (eg, Black and Parda/Brown women with lower educational levels) can WHO's global health initiative to eliminate mother-to-child transmission of syphilis be made feasible. Recognising that racism and other intersecting forms of oppression affect the lives of minoritised groups and advocating for actions through the lens of intersectionality is imperative for attaining and guaranteeing health equity. Achieving health equality needs to be addressed to achieve syphilis control. Full-Text PDF Open Access